The Shoulder Arthroplasty Smart (SAS) score is a new, validated machine learning-derived outcome measure that requires six input parameters. The SAS score has the potential to replace legacy shoulder outcome scores. We conducted a retrospective review of a multinational shoulder arthroplasty database of one platform shoulder prosthesis (used interchangeably for anatomic and reverse total shoulder arthroplasty). All primary shoulder arthroplasties with a minimum of two-year follow-up and an available SAS score were evaluated. Associations between scoring systems were assessed using Pearson correlations, with 95% confidence intervals stratified by time point (preoperatively and postoperatively at 2- and 5-year follow-ups, respectively) and procedure (anatomic verses reverse total shoulder arthroplasty). Conversion equations were developed using the best-fit line from linear regression analysis. Ceiling effects were assessed based on two definitions: (1) >15% of participants scoring the maximal possible score and (2) a standardized distance less than 1.0, whereby the standardized distance is calculated by subtracting the mean from the maximal score and dividing by the standard deviation. Two thousand four hundred six shoulders were evaluated at 4,553 clinical encounters. For preoperatively collected data, the SAS score correlated strongly with the Constant (R = 0.83), University of California at Los Angeles (R = 0.85), and Shoulder Pain and Disability Index (R = -0.70) scores and moderately with the American Shoulder and Elbow Surgeons (R = 0.69) and Simple Shoulder Test (R = 0.65) scores. The SAS score strongly correlated (R > 0.7) with all legacy outcome scores collected at 2- and 5-year postoperative visits. Score predictions made using the conversion equations between the SAS score and legacy outcome scores strongly correlated with their actual values. Neither the SAS nor the Constant score were influenced by ceiling effects. All other outcome scores evaluated demonstrated ceiling effects. The SAS score correlates well with legacy shoulder scores after primary shoulder arthroplasty while mitigating ceiling effects. Surgeons may decrease patient questionnaire burden by using the brief six-question SAS score.

The Open Payments Database (OPD) provides transparent reporting of all payments made to physicians from private industry. Previous studies have described the nature of these financial relationships using the first year of publicly available data. However, long-term trends of these relationships have not been well described. Therefore, we report on the value and distribution of payments within the OPD and analyze trends of payments made to orthopaedic surgeons from 2014 to 2018. The OPD was queried from 2014 to 2018. Payments within the database were categorized into (1) general payments, (2) research interests, and (3) ownership interests. We report on the number, value, and payment trends between private industry and all licensed orthopaedic surgeons who have completed residency training. A total of 631,000 physicians and 23,859 orthopaedic surgeons were included, representing 79.8% of US board-certified orthopaedic surgeons (n = 29,908). Although orthopaedic surgeons received an average of 2.9% of the number of payments made annually, payments to orthopaedic surgeons represented 10.0% of the value of payments made to all physicians. From 2014 to 2018, payments to orthopaedic surgeons increased in both number and value, from 313,194 separate payments ($883.8 million) in 2014 to 335,815 separate payments ($958.6 million) in 2018. In 2018, the top 1% of orthopaedic surgeons (n = 239) accounted for 58.0% ($265.8 million) of all payments to the field. Despite representing only 2.4% of the number of general payments, royalties represented 68.9% ($290.4 million) of the value of general payments to orthopaedic surgeons. Payments for research and education both increased. Industry payments to orthopaedic surgeons represent 10.0% of all physician payments, with increases in payments for research and education. Royalties represented most (68.9%) of the value of general payments made to orthopaedic surgeons. Transparency in physician payments from industry is essential to avoid conflicts of interest. Level III.

Bilateral symptomatic femoroacetabular impingement (FAI) is common. However, the fate of asymptomatic hip in patients with the radiographic diagnosis of bilateral FAI and unilateral symptoms remains unknown. (1) What is the likelihood of the asymptomatic hip becoming painful in patients with unilateral symptoms but with radiographic evidence of bilateral femoroacetabular impingement? (2) What radiological and clinical factors are associated with the development of symptoms in an asymptomatic hip diagnosed with FAI? A longitudinally maintained institutional FAI database was queried to collect relevant data for this retrospective study. To answer our research questions, we created a cohort of patients with bilateral radiographic signs of FAI but only unilateral symptoms at the time of initial presentation. Between 2004 and 2016, a senior surgeon (JP) at one institution treated 652 patients for hip pain determined to be from FAI, a diagnosis we made based on clinical symptoms, physical exam, and diagnostic imaging. We excluded 95 patients (15%) because of inadequate data or other diagnoses, which left 557 patients. Of those, 170 patients (31%) had bilateral radiological diagnosis of FAI, and 88 (52%) of them had bilateral hip symptoms, and so were excluded. Of the remaining 82 patients, eight (10%) underwent bilateral FAI surgery under the same anesthetic despite having only unilateral symptoms, leaving 74 for analysis in this study. Patients were followed with annual clinic visits, or contacted by phone and electronically. We defined onset of symptoms using a modified Harris Hip Score (mHHS) or the University of California at Los Angeles (UCLA) activity scale, and used a logistic regression model to identify factors associated with the development of symptoms. Of the 74 patients with bilateral FAI and an asymptomatic hip at initial presentation, 60 (81%) became symptomatic at a mean 2 years (range, 0.3-11 years) followup. Of these 60 patients, 43 (72%) eventually underwent subsequent surgical intervention. After controlling for potential confounding variables such as sex, age, BMI, history of trauma we identified that reduced neck-shaft angle (r = -0.243, p = 0.009), increased lateral center-edge angle (r = 0.123, p = 0.049), increased alpha angle (r = 0.069, p = 0.025), and younger age (r = -0.071, p = 0.046) were associated with the development of symptoms in the contralateral hip. With the numbers available, none of the other examined variables such as sex, BMI, history of trauma, psychiatric condition, employment, Tönnis grade, Tönnis angle, crossover sign, type of impingement, and joint congruency were found to be associated with symptom progression. Bilateral FAI may be observed about one-third of patients. Most patients with unilateral symptomatic FAI and radiographic diagnosis of bilateral FAI in this cohort became symptomatic relatively quickly and most of them underwent subsequent surgical intervention in the contralateral hip. Reduced neck-shaft angle, increased lateral center-edge angle, increased alpha angle, and younger age were associated with symptom development in the contralateral hip. Hip preservation surgeons may use the finding of this study to counsel patients who present with bilateral FAI but only unilateral symptoms about the natural history of their condition. Level III, therapeutic study.

Diagnosing periprosthetic joint infection (PJI) represents a challenge that relies on multiple clinical and laboratory criteria that may not be consistently present. The synovial alpha-defensin-1 (AD-1) test has been shown to correlate accurately with the Musculoskeletal Infection Society (MSIS) criteria for the diagnosis of PJI, however, its association with persistent PJI has not been elucidated in the setting of patients receiving antibiotic spacers during second-stage reimplantation. Applying a Delphi-based consensus to define successful eradication of PJI offers an opportunity to test the utility of AD-1 in this setting. (1) Can the AD-1 test determine whether infection has been controlled using the Delphi criteria for persistent PJI as a surrogate for infection eradication during two-stage revision for PJI treatment with a spacer? (2) How does the performance of the AD-1 test compare with the MSIS criteria? This was a multicenter analysis of retrospectively collected data on patients who underwent a two-stage revision arthroplasty between May 2014 and July 2016. We included patients who had a previously confirmed PJI and received a cement spacer, underwent the second stage, had MSIS criteria data and a synovial fluid AD-1 test, and had a minimum followup of 1 year. We were unable to determine for all study sites how many patients had the test but did not meet all the criteria and so could not be studied; however, we were able to identify 69 patients (43 knees, 26 hips) who met all criteria. During the period in question, indications for use of AD-1 varied by surgeon; however, during that time, in general if a surgeon ordered it as part of the initial workup, the test would have been repeated before the second-stage reimplantation procedure. To assess the validity of AD-1 against persistence of PJI criteria at 1 year, the following were calculated using the Delphi criteria for persistent PJI as the gold standard: sensitivity, specificity, positive and negative predictive values, accuracy, and area under the curve (AUC) with 95% confidence intervals (CIs). Concordance index (c-index) and its Wald 95% CI with receiver operating characteristic (ROC) curve were calculated in relation to Delphi criteria for persistent PJI using AD-1 and then MSIS criteria. The two c-indices of AD-1 and MSIS were compared using the DeLong nonparametric approach. The AD-1 test showed poor sensitivity (7%; 95% CI, 0.2-34), and poor overall accuracy (73%; 95% CI, 60-83; AUC = 0.5; 95% CI, 0.3-0.6) in detecting infection eradication at 1 year. The c-index for AD-1 versus Delphi criteria for persistent PJI was 0.519 (95% CI, 0.44-0.60), and the c-index for MSIS criteria versus Delphi criteria for persistent PJI was 0.518 (95% CI, 0.49-0.54), suggesting the weak diagnostic abilities of these models. The contrast estimate between MSIS criteria and AD-1 were not different from one another at -0.001 (95% CI%, -0.09 to 0.09; p = 0.99). We found that a positive synovial fluid AD-1 test correlated poorly with the presence of persistent infection 1 year after two-stage revision arthroplasty for PJI. For this reason, we recommend against the routine use of AD-1 in patients with cement spacers, until or unless future studies demonstrate that the test is more effective than we found it to be. Level IV, diagnostic study.

The number of patients undergoing hip arthroscopy for labral tears has increased, but labral tears are sometimes seen in asymptomatic patients with femoroacetabular impingement (FAI). The frequency of this finding, however, has not been well characterized nor is the proportion of patients with previously asymptomatic labral tears who may later become symptomatic. The purpose of this study was to determine (1) the prevalence of labral tears and other intraarticular pathology in the asymptomatic contralateral hip of patients undergoing surgery for symptomatic FAI; (2) the likelihood that the asymptomatic hip had become symptomatic at latest followup; and (3) any association between MRI findings and age, sex, and body mass index (BMI) in both symptomatic and asymptomatic sides. This study included patients who were diagnosed with unilateral symptomatic FAI between 2013 and 2015 and who had an available MRI of both hips. The study included 100 patients (47 females, 53 males) with a mean age of 33 years (range, 17-57 years). Patients with a symptomatic contralateral hip (n = 56) or an unsuitable MRI for review based on both reviewers' consensus (n = 344) were excluded. The MRI of both hips was independently evaluated by two orthopaedic surgeons and interobserver reliability tested. The interobserver reliability for the two surgeons' MRI ratings was almost perfect (κ ≥ 0.85). The presence of a labral tear, an acetabular chondral lesion, subchondral acetabular cysts, and fibrocystic changes in the femoral head-neck junction was documented for both hips. At latest followup, asymptomatic hips were investigated for any symptomatic labral tears or surgical procedures resulting from FAI. A labral tear was recorded in 97 (97%) and 96 (96%) of symptomatic hips, respectively, for each surgeon's evaluation. A labral tear was also detected in 41 (41%) and 43 (43%) of asymptomatic hips. In addition, an acetabular chondral lesion was detected in 32 (32%) and 35 (35%) of the symptomatic hips and 15 (15%) and 17 (17%) of the asymptomatic hips. At latest followup, nine of the patients were diagnosed with symptomatic labral tears in the contralateral asymptomatic hip and were treated. None of the radiologic parameters examined demonstrated an association with patient age, sex, or BMI in either symptomatic or asymptomatic hips. Labral tears and acetabular chondral lesions are common in the asymptomatic contralateral hip of patients undergoing surgery for FAI. The incidence of a symptomatic labral tear in these asymptomatic hips was 9% during 2 years of followup. We suggest that the decision to perform chondral or labral surgery in patients with FAI should be made with caution considering the relatively high prevalence of labral tears in asymptomatic hips and the low chance of development of symptoms. Level IV, case-series study.

To aid implementing an ethics curriculum in an orthopaedic residency program, the American Academy of Orthopaedic Surgeons (AAOS) created 14 ethics scenarios. Because delivery of this curriculum could be burdensome, an online module-based curriculum might be optimal. Two cohorts of orthopaedic residents participated: cohort I completed 14 online ethics modules converted from the 14 AAOS ethics scenarios. For each module, we gave a multiple-choice assessment immediately before the module, immediately afterward, and 3 months afterward. Cohort II completed only the 14-module assessments at similar time intervals without any educational content. Cohort I demonstrated improvement in 3-month postmodule assessment scores in 11 of the 14 modules, 3 of which had statistical differences in baseline scores for cohort I and cohort II. We observed no statistical difference in scores within cohort II on repeat testing. This study demonstrates that 11 of the 14 AAOS ethics scenarios, converted to online modules, teach ethical concepts to orthopaedic residents. Orthopaedic residency programs may find it valuable to engage their residents in the ethics scenarios created by the AAOS to complement their ethics curriculum.

Venous thromboembolism (VTE) prophylaxis is recommended for all patients undergoing total hip arthroplasty or total knee arthroplasty. The selection of an appropriate prophylaxis regimen represents a balance between efficacy and safety. To help orthopaedic surgeons select an appropriate VTE prophylaxis regimen for their patients, the American Academy of Orthopaedic Surgeons and the American College of Chest Physicians have developed guidelines. These guidelines do not recommend an optimal regimen, however. Rather, an individualized prophylaxis regimen that balances efficacy and safety is recommended for each patient, based on various risk factors. Because of a paucity of data and a lack of adequately powered head-to-head trials, implementing these guidelines can be challenging for the orthopaedic surgeon. Knowledge of the prophylaxis options and the VTE risk factors is paramount for developing an effective VTE prophylaxis algorithm for the surgeon's practice.

Total hip arthroplasty has been utilized for the past 50 years as an effective treatment for degenerative, inflammatory and traumatic disorders of the hip. The design of these implants has generally followed the anatomy of the hip as a ball and socket joint with the femoral head representing the ball and the acetabulum representing the socket. We describe a novel hip arthroplasty design in which the “ball” is located on the acetabular side and the “socket” is located on the femoral side. The results of extensive biomechanical testing are described and document wear and corrosion characteristics that are at least equivalent to standard designs. These results support clinical assessment as the next step of the evaluation.

To date, no study has reported on the public's opinion of orthopaedic resident duty-hour requirements (DHR). A survey was administered to people in orthopaedic waiting rooms and at three senior centers. Responses were analyzed to evaluate seven domains: knowledge of duty hours; opinions about duty hours; attitudes regarding shift work; patient safety concerns; and the effects of DHRs on continuity of care, on resident training, and on resident professionalism. Respondents felt that fatigue was unsafe and duty hours were beneficial in preventing resident physician fatigue. They supported the idea of residents working in shifts but did not support shifts for attending physicians. However, respondents wanted the same resident to provide continuity of care, even if that violated DHRs. They were supportive of increasing the length of residency to complete training. DHRs were not believed to affect professionalism. Half of the respondents believed that patient opinion should influence policy on this topic. Orthopaedic patients and those likely to require orthopaedic care have inconsistent opinions regarding DHRs, making it potentially difficult to incorporate their preferences into policy.